Disclaimer
Hazards
Great care has been taken to maintain the accuracy of the information
contained in this publication. However, the publisher and/or the distributer
and/or the editors and/or the authors cannot be held responsible for
errors or any consequences arising from the use of the information
contained in this publication. The statements or opinions contained in
editorials and articles in this publication are solely those of the authors
thereof and not of the publisher, and/or the distributer, and/or the IIF.
The products, procedures and therapies described in this work are
hazardous and are therefore only to be applied by certified and trained
medical professionals in environment specially designed for such
procedures. No suggested test or procedure should be carried out
unless, in the user‘s professional judgment, its risk is justified. Whoever
applies products, procedures and therapies shown or described in this
publication will do this at their own risk. Because of rapid advances in
the medical sience, IF recommends that independent verification of
diagnosis, therapies, drugs, dosages and operation methods should be
made before any action is taken.
Although all advertising material which may be inserted into the work
is expected to conform to ethical (medical) standards, inclusion in this
publication does not constitute a guarantee or endorsement by the
publisher regarding quality or value of such product or of the claims made
of it by its manufacturer.
Legal restrictions
This work was produced by IF Publishing, Munich, Germany. All rights
reserved by IF Publishing. This publication including all parts thereof, is
legally protected by copyright. Any use, exploitation or commercialization
outside the narrow limits set forth by copyright legislation and the
restrictions on use laid out below, without the publisher‘s consent, is
illegal and liable to prosecution. This applies in particular to photostat
reproduction, copying, scanning or duplication of any kind, translation,
preparation of microfilms, electronic data processing, and storage such
as making this publication available on Intranet or Internet.
Some of the products, names, instruments, treatments, logos, designs,
etc. reffered to in this publication are also protected by patents and
trademarks or by other intellectual property protection laws« (eg. «IF«,
«IIF« and the IF-Logo) are registered trademarks even though specific
reference to this fact is not always made in the text.
Therefore, the appearance of a name, instrument, etc. without
designation as proprietary is not to be construed as a representation by
publisher that it is in the public domain.
Institutions‘ subscriptions allow to reproduce tables of content or
prepare lists of Articles including abstracts for internal circulation
within the institutions concerned. Permission of the publisher is required
for all other derivative works, including compilations and translations.
Permission of the publisher is required to store or use electronically
any material contained in this journal, including any article or part of an
article. For inquiries contact the publisher at the adress indicated.

Typical contents in ID
• Evidence Reports summarize the latest «Hot Topics» from relevant journals putting similar
studies «side-by-side». This unique presentation of studies allows you to compare and contrast the
patient populations, the treatment interventions, and the quality of the scientific methods. The
«evidence-based bottom line» is presented with an overall summary statement at the beginning.
Clinical notes by implantologists with special expertise on the topic complete the Evidence Report
by providing their expert clinical opinion. ID is an implantology publication that provides attention
to detail in balancing science with clinical opinion in such a clear, concise, and visually-friendly
presentation.
• Literature Analyses provide you with an in-depth look at the research on a given topic.
A «Literature Analysis» is a critical review of the literature on the epidemiology, treatment
methods, and prognosis for implant-related topics or conditions. Literature Analyses are broader
than «Evidence Reports» and are written to serve as a reference tool for implantologists to help
them make decisions regarding how to manage patients, to assist them in evaluating needs for
future research, and to use the material for future presentations.
• Critical Appraisals summarize the findings from important papers used for clinical decision
making or marketing by implant companies. In addition to the summary, the study‘s methods and
clinical conclusions are critically reviewed in an effort to challenge the implantology community
into not accepting everything that is published, while fostering alternative explanations and ideas.
• Case reports give implantologists the opportunity to publish on unique patients using innovative or
alternative methods for treating challenging patient conditions.
• Research in Context is a helpful «what is» section to consult if you’ve ever read a study and
asked «what is a p-value» or any other research method question. It assists clinicians with
the critical evaluation of the literature by briefly describing relevant aspects of research
methods and statistical analysis that may bias results and lead to erroneous conclusions.

CMF.Impl.Dir. Vol. IV 2010

101

Editorial
Funding for implants
Dental implantology takes place in a field
between medical/surgical interventions and
cosmetics.
In some European countries like in Germany,
treatment providers have tried hard to position
dental implantology in the field of medicine in
order to get funding from the health insurers.
This opened a large field of discussions,
regulations and enormous amounts of money
and time were spent for these useless efforts
to take money out of the community`s pocket.
One working minute at the chair is associated
in Germany with more than 30 seconds of
paperwork. This is ineffective.
In France, for many years, treatment providers
were sick of arguing with health insurers and
they positioned dental implantology clearly in
the cosmetic field. Therefore patients had to
pay out of their own pockets for the treatment
and the implantologist did not argue with clerks
of the insurance at all. They were right away
able to direct treatment towards the patients
needs, regardless of “regulations”. With the
economic crisis developing, some treatments
are moved back into the field of public funding.
In Switzerland the placement of two implants
in the area between the mental nerves plus
a full denture fixed thereon is covered by a
state insurance but not necessarily by the
health insurance. The state insurance pays
only for those patient`s, who can prove that
they can`t afford this “simple treatment”. Thus

102

two implants for the secure fixation of the
lower denture are considered the minimum
amount of treatment, the minimum quality of
life, which every citizen in Switzerland should be
able to get. All other implants are not covered
and the question whether the treatment is a
completely medical one may be left open.
In Germany a young man is suitable for serving
in the German Army even with severe oral
malfunctions, deformations and abnormalities,
missing teeth, etc., as long he is able to
maintain his body-weight in comparison to his
body-height within a broad limit.
In the Swiss medical system, on the other
hand, dental treatments are not covered
(except cases where the problem is based
on congenital defect`s etc.), and the rejection
of the coverage is made on grounds of the
assumption, that teeth-loss or decay is always
based on the patient`s own fault (lack of
cleaning, lack of maintenance). The Swiss dental
association fights strongly for keeping dentistry
outside of any state-ruled insurance.
In Russian speaking countries the treatments
provided by the state are restricted to the
lowest possible standard, but they include
crowns and bridges. Implants are not available
in this basis. The reason is, that educated
treatment providers who are knowledgeable
about implant, simply will not even think of
doing this kind of work inside state premises.
Patients receive some minimal treatment
in state clinics (consider this as a “patient
catcher”), and they are then referred to the

private office (often run by the same treatment
provider) for the implant treatment.
Since patients can eat and live with soft tissue
born dentures or even without teeth at all, the
question, whether or not dental implantology
should be covered by insurances at all must be
raised strongly.
There are good arguments for categorizing
dental implantology into the field of cosmetics
and there are arguments against it. The fact
that the treatmant provider by law has to be a
licensed dentist or surgeon alone, will not justify
the strict classification as a medical invention.
Note that liposuction and botox-applications
(just to name two examples) are carried out
by physicians and yet everyone will understand,
that the major issue of those treatments is a
cosmetic one in most of the cases.
Cosmetic
interventions
and
medical
interventions differ though with regard to
the informed consent, with regard to patient
information and decision making, and regarding
electivity. Furthermore medical interventions
can`t take place without medical indications,
whereas cosmetic interventions can.

least better) care of the incorporated workpieces, if he/she himself/herself had to pay
for it. We should strive to continue working
for real, patient derived money, as long as it is
available and has a value.

Munich, December 2010

Prof. Dr. Stefan Ihde

It seems that all efforts of state organizations
to claim that the states will provide good and
affordable dentistry are in vain. The reality
shows, that the patients have to provide his/
her own money for reasonable treatments,
especially for dental implants. This is clearly
an advantage, as this payment is usually
connected with the patient taking good (or at

CMF.Impl.Dir. Vol. IV 2010

103

1. Introduction
At the onset of dental implantology a variety
of implant designs was proposed and used.
Later industry focused on producing bullet-type
of implants and influenced the universities to
“research” and teach into this direction. This
finally influenced the thinking of the treatment
providers to an extent, that many of them are
unable to follow or understand a different way
of thinking.
Dental implantology and orthopedic surgery
were developing independently, without a fruitful
exchange of ideas and experiences. Therefore
the use of cortical bone was never advocated in
the dental field, and the mainstream in dental
implantology is until today still in doubt about
the possibilities of immediate loading protocols
and the usage of cortical bone and corticalized
bone. The option of corticalizing spongious bone
through compression screws on the other hand
is to our knowledge not used in the field of
orthopedic surgery.
Basal implantology closed this gap and
introduced proven concepts of orthopedic
surgery into our dental field. Basal implantology
is a new category with new, broad indications
and almost no limitations. Basal implants
broadens the spectrum of implantology, without
necessarily competing with traditional concepts.
The technology allows to treat virtually every
case immediately, safely and effectively. This
also increases the productivity of the dental
office dramatically.

104

Fig. 1: While in some areas of this world even
the traditional dental implantology is still fighting
for this acknowledgement, the category has
divided up in other areas. Basal implantology is
based both on the dental knowledge(regarding
prosthetics and function) as well as on proven
surgical principles and concepts of the
orthopaedic surgery. As a rule never bone
augmentations are used to provide anchorage
for basal implants. Instead optimum use of the
available bone is made.
As per definition, basal implants consist of
one or several base-plates or macro-retentive
(retentive) threads, which are connected to a
vertical implant part (or shaft), the latter holding
an abutment (one piece designs) or an internal
or an external thread for abutment connection
(two piece designs). Lateral basal implants (e.g.
commercial brands like Diskimplant®, BOI®, TOI®)
are inserted from the lateral aspects of the
jaw bone and anchored strictly trans-osseously
in cortical bone structures. Basal implants
transmit loads primarily (and initially only) into the
cortical bone areas, and they do not necessarily
have to be osseo-integrated (primarily or at

all) in spongious bone or empty areas (like the
maxillary sinus). Basal screw implants are
considered from a functional point of view as
basal implants, because they are anchored
in basal cortical bone regions in the cortical
opposite to the alveolar crest. They provide
no surface enlarging for load transmission in
the vertical implant parts and they provide no
3D-compression. All basal implants belong to
the group of osseo-integrated implants. Some
basal implants provide in addition the possibility
to be in part or only used as a sub-periosteal
implant designs.
Basal implantology avoids bone augmentation.
In selected cases augmentations are
nevertheless performed to increase the volume
for aesthetical reasons, even in combination
with basal implants. However: augmentations
are today never necessary for the sake of
creating bone to fixate the implant.

Fig. 3: Basal Implant with a base-plate of 9 x
16 mm and a shaft height of 6 mm (BOI® BAST
9/16, or TOI®). The base-plate of this BOI®-design
may be turned after the inserting the implant.
This way high primary stability is gained. The
serrated flat end of the implant interlocks
in the vestibular cortical. These designs are
turned inside the bone after they have been fully
inserted.

Fig. 4: Compression screw implants (KOS®,
GCS®) are not considered to be basal implants.
They nevertheless allow immediate loading,
because the surrounding bone is compressed
during the insertion of the implant. The bone
thereby corticalizes (becomes more dense, while
the osteonal bone structures are damaged),
remodeling is delayed, and the compressed
peri-implant bone cannot be the origin of the
remodeling process. However these bone areas
can be still the target of the remodeling.

CMF.Impl.Dir. Vol. IV 2010

105

At the first glimpse the devices displayed in
Figures 2 and 3 seem to have nothing to do with
each other. In practical use however, they are
absolutely identical regarding the purpose of the
design: Both implants are designed to create
cortical anchorage in the cortical. BOI®-implants
utilize the lateral corticals of the jaw bone, while
BCS®-implants with large threads utilize the
basal cortical and the lateral corticals.
“Other than conventional implants, basal
implants use macro-retentive elements of their
design to allow immediate loading. They are
anchored purely in native cortical bone.”
According to the traditional thinking in dental
implantology it is assumed that implants
become osseo-integrated, and that this process
is somehow connected or supported by the
properties of the surface of the implants. When
using basal implants or the KOS® system, we
are utilizing cortical bone areas and as soon
as the implant gains direct contact to highly
mineralized cortical or corticalized bone it can
be considered as functionally already osseointegrated. This gives us the opportunity and the
justification for an immediate load protocol.
Although they are skelettonized, basal implants
provide exactly what is needed by the dentists to
satisfy the needs of the patient:
Stable intra-oral abutments, through cortical
anchorage
• The transition area between the infectionfree basal bone area and the mouth serves
as a safety-distance.

• A thin mucosal penetration area as a
prophylactic means against peri-implantitis.
• A cementing or screw-on abutment, or a
screw connection for safely connecting
prosthetics
• A polished surface for the prevention of
infections (just as orthopaedic implant
screws and devices)
Traditional crestal implantology no doubt
offers optimal ways of restorative treatment
in situations where the implants can be
inserted without delay and with no need for
adjuvant procedures. Unfortunately, a great
many patients do not meet these criteria.
This is particularly true of the posterior
segments of the maxilla and mandible. Whenever
oral conditions are less than ideal for crestal
implants, the advantages of the basal approach
are obvious:
• Low degree of invasiveness (no augmentation,
distraction or transplantation)
• A one-step procedure
• Simple repair in case of problems or implant
exchange
• Combination with crestal implants and even
with teeth (in selected cases)
• Simple laboratory technique
• Extremely high success rates

106

• If screwable designs are used, in most cases
a flapless procedure is sufficient. This way
placing implants has mutated to an extreme
non-invasive procedure.

an emerging profile. It is true, that KOS®, BCS®
and BOI® implants do not provide an emerging
profile and the good reasons for this have been
mentioned. In fact, good aesthetics may be
reached without an emerging profile, and the
results are long-lasting.

Disadvantages of the basal implant systems
include:
• The stock-keeping requirements in the daily
practice are slightly greater than in crestal
implantology, i.e. it will always be necessary
to keep an assortment of implant types
handy to avoid extensive planning. Of course,
extensive (3D-) pre-operative planning is
an alternative for keeping stock, however
keeping a stock is cheaper.
Fig. 5a:
• The technique of lateral basal implants
poses substantial challenges, for instructors
and users alike, as far as the surgical and
prosthetic treatment stages and the
substantial knowledge requirements in the
fields of biomechanics and bone physiology
are concerned. An outline of the necessary
knowledge is found in the textbook
“Immediate loading” which is available from
the International Implant Foundation.
From a business perspective, however, these
disadvantages turn out to be advantages
after all, since mastering the learning curve
will give dentists a comfortable edge over any
competitors in the field of implantology.
It has been discussed that the devices shown
here do not allow the creation of aesthetical
solutions, because the dentist cannot deliver

Fig. 5 b
Fig. 5a and 5b: Compression screw implants
were seated in the mandible and in the maxilla.
Although the implant-heads are only max.
3.45mm in diameter, an extremely satisfying
and durable clinical result (The upper jaw is
shown 12 years postoperatively) is possible.

CMF.Impl.Dir. Vol. IV 2010

107

3. The Treatment plan
Basal implants (BOI®, BCS®) may be used as
support for bridges. In some indication their
use as single tooth implants is possible. In
general we recommend to use in healed bone
areas a KOS® implant instead of basal implants.
The reason is, that the KOS® implant with its
roughened surface shows better resistance
against rotation.
For segments and full bridges we prefer basal
implants, because they are easier to use and the
risk of infection is smaller. BCS® and BOI® are
suited for placement into extraction sockets.
Actually the preferred way of treatment is to
insert the implant right after the extraction and
not to wait for the “healing” of the socket.

The rationale behind this is, that the socket
walls undergo remodelling after the extraction.
This remodelling weakens the bone structures
for a long period (up to two years) and the
weakened bone provides less resistance for the
implant under immediate load conditions.
For full bridges the area of the canines and
of the 2nd molars is equipped with implants.
Additional implant between these “strategic
areas” can help to secure the treatment success
in immediate loading protocols. In the maxilla
the last implant is typically a tubero-pterygoid
screw. BCS® implants are well suitable for this
purpose. The distal mandible is typically treated
with a BAST-implant (Fig.3). For canunes either
long BCS® or triple-BOI® implants are suitable.
Fig. 6

108

Fig. 6: Technical abutments at the side of a full
bridge in a case with extremely strong resorbtion.
The masticatory surfaces are created ideally,
because they are the pathways for a bilateral
and balanced mastication. Note that the baseplates are much wider than the vertical part of
the implant, and this results in a direct support
of the masticatory surfaces. All occlusal contact
points and all functional surfaces are located
within the supporting polygon marked by the
base- plates of the implants.

Fig. 7.: The upper jaw is equipped with 8 KOS速
screw implants and two STC tubero-pterygoid
screws. The usage of angulated KOS速A 25o
right in front of the sinus allows reduction of the
otherwise wide span from the anterior implants
to the tubero-pterygoid screw. Note that this
bridge is cemented on the KOS速 implants and
screw-connected to the distal SCT-implants.
Avoiding the sinus and nevertheless reducing the
span of the bridges is one of the key strategies
in basal osseointegration.

Fig. 7

CMF.Impl.Dir. Vol. IV 2010

109

We tend to use basal implants with only one
disk-plate in the distal mandible and prefer to
put no implants at the premolar positions for
full bridges, to ensure that the elasticity of the
mandible is not overly reduced and that no
fulcrum is created in the middle of the horizontal
part of this bone. Triple- and double-disk BOI®
implants can be used to good effect along the
anterior block of the mandible.
When considering a tooth as part of a larger
bridge, it should be considered that overall
masticatory forces will increase. In general the
maxilla should be treated with 8-10 implants:
“Never underequip the maxilla! (citation from:
Prof. Dr. Gerard Scortecci)”

Which jaw should be restored first?
Concerning the issue as to which jaw should be
restored first, we have developed the following
approach in our clinic: if implant treatment
is needed in both jaws, both jaws should be
treated simultaneously. Sometimes patients do
not agree to this treatment, i.e. because they
have not full trust in implants or because they
cannot afford treatment in both jaws right away.
In these cases the mandible should be treated
first. There are several reasons for this decision:

110

• Complete dentures are not retained nearly
as well in the mandible as in the maxilla.
Therefore, the need to provide treatment is
typically greater in the mandible.
• In many cases, additional implant treatment
in the maxilla turns out to be redundant
once a fixed restoration has been inserted
in the mandible. The patients adapt easier
to an upper full denture.
• The morphological changes in the mandible
are often substantial, particularly in the
wake of adjustments performed to reestablish a normal masticatory pattern.
Simultaneous placement of implants in the
maxilla and mandible carries a high risk of
overloading the newly inserted implants in
the maxilla. Relative elevation of the distal
implants is especially liable to inflict damage
to maxilla. Conditions are more favourable
once the functional adaptation after implant
placement in the mandible have been largely
completed.
Note however, that the mandible alone may only
be treated, if the maxilla offers a satisfactory
opposing dentition, aligned to the plane of
Kamper, and correct curves of Spee and Wilson.
If the mandible is restored against an unsuitable
maxillary dentition, various problems may arise
and often in combination of the treatment of the
upper jaw with implants, a new fabrication of
the lower bridge (free of charge) is required.
Should, in these cases, problems with the lower
bridge and implants arise before the upper jaw

has received implants, the patient may lose
trust in the procedure and deny the treatment
in the upper jaw.
Clinical experience shows that the ability to
eat increases after inserting a mandibular
restoration supported by implants. Chewing
function was significantly improved once these
restorations were in place. In patients on
a limited budget, a cost-benefit analysis will
therefore definitely argue in favour of providing
an implant-based solution in the mandible rather
than the maxilla. This strategy will be effective
in the majority of patients and will often render
additional treatment of the maxilla redundant
(See: Lee A.J.C., Albrektsson T, Brånemark P.I.
(eds.): Clinical Application of Biomaterials. John
Wiley & Sons Ltd.). Thereby the approach is very
cost-effective.
We feel that this view needs to be put into
perspective, as considerable progress has been
made with implant treatment in the maxilla since
1982. With today’s BOI® and BCS® technology,
implant-supported fixed restorations have
become just as affordable, successful and
simple to realize in the maxilla as they have been
in the mandible for quite a time.
If a complete denture is present in the maxilla,
the necessary (mostly distal) elevation of the
occlusal plane towards Kamper’s plane can be
performed more readily than in the presence
of a fixed restoration or of elongated natural
teeth. Trying to save money on this aspect of
treatment will be counter-productive in the long
term.

Treating only one jaw is not recommended in
cases where:
• in the opposite jaw teeth from 6 -6 are not
present and cannot be restored without
implants. An unequal arch length in the
non treated jaw will lead in most cases to
a unilateral pattern of chewing. This leads
inevitably to an unequal distribution of bone
mineralisation and subsequently to problems
on the tension side.
• unilateral or anterior chewing patterns
prevail and cannot be eliminated on the
existing dentition.
• the bite must be raised in both jaws in order
to adjust the vertical dimension.
• the plane of bite cannot be aligned to the
plane of Kamper: this is very often the case in
class II subdivision 2 cases. After elongation
of both frontal segments and tooth loss in
the distal mandible those patients present a
plane of bite which is significantly too much
caudally in the distal jaws. If this is to be
corrected, usually
• all lower front teeth have to be extracted
and the extraction of the canines must be
considered
• a vertical reduction of the bone between the
mental nerves often has to be performed
(the necessary reduction is 0.3 – 1 cm)

CMF.Impl.Dir. Vol. IV 2010

111

â&#x20AC;˘ the vertical dimension must be raised, and
elongated upper molars and pre-molars
must either be shortened or extracted.
â&#x20AC;˘ It is recommended to raise the bite in one
step and even to raise it slightly more than
initially necessary. This will allow a slight
reduction of the vertical dimension during
the adjustment phase, without creating an
overly strong engagement of the front teeth.
To avoid this, the front teeth must have
enough free space at all times.
Single tooth restorations on basal implants
Replacing single teeth with basal implants is
a good option for the trained implantologist.

It requires good intra-operative vision and
planning, because once the horizontal slots have
been performed, the position of the slots cannot
be changed. Therefore starting at the correct
height is vital. Except for the replacement of first
upper molars, and lower 2nd molars all positions
are suitable for single BOI implant placement.
Whenever a healing time is acceptable or
required, the internal system (IDO, IDDO, IDDDO)
may be used. The head of those implants are
partly submerged and placement of a healing
screw is required as the following two case
reports show. The beauty of this procedure is
that implantologists trained on screws are well
able to do the prosthetical work on IDO implants
and they only have to learn the slightly different
insertion technique.

Fig. 8: An individual abutment was casted (Co CrMo) and is tried in.

112

Fig. 9.: Perfect integration of the basal implant
with visual corticalization of the bone adjacent
to the base plates. The grafted area seems to
be connected to the native bone. The distance
between the bone and the crown-to-implant
connection is approximately 1.5 mm. This case
was treated using the early reopening technique
(ERT, see below)

Fig. 10.: The decision to create a lateral (12) rather than a canine was taken in close communication
with the patient. No request for improvement of the soft tissue situation.

CMF.Impl.Dir. Vol. IV 2010

113

4. Handling KOS® and BCS®-implants
4.1. The flapless approach
Whenever the horizontal bone supply (width)
is adequate, the flapless insertion technique
should be used. Avoiding a flap helps preserve
the bony flow of nutrients unchanged and avoids
the occurrence of a regional acceleratory
phenomenon (RAP). Therefore the available
spongeous bone remains constant after implant
placement.
Experienced surgeons manage to place
KOS and BCS implants even into very narrow
ridges without creating a flap. In fact, a flapless
approach is always worth trying. The morphology
of the alveolar crest may be explored bi-digitally
or with the help of the injection needle.
The osteotomy in the upper jaw may be
prepared or carried out with the help of the
handgrip, the adapter, and the thin yellow
pathfinder drill (BCD 1). Only if the bone becomes
very hard, the blue contra-angle may be used to
gain an osteotomy in an adequate length.
Whenever it is possible, the osteotomy also for
KOS implants in the upper jaw should reach the
opposite cortical and penetrate it slightly. The
implant placed therafter should also reach this
cortical. As a rule, roughened implants (KOS®,
KOS®B, KOS®A, KOS®E, KOS®EB) may penetrate
the cortical towards the nose or the maxillary
sinus approximately 1 mm without creating
a problem. BCS may penetrate into any depth
or even transverse the sinus to reach a stable
cortical areal. The reasons for this are that
BCS® implants are completely polished and
for this reason they are not prone to bacterial

114

colonisation. Furthermore they have a thin
mucosal penetration diameter.
When planning the osteotomy take into
consideration, that in many cases the densitiy
of the bone around the osteotomy is different
at different sides. As soon as a compression
screw or a BCS® is placed into a cavity smaller
than the threads, the screw will be forced into
the direction of the weaker bone areal. This may
lead to a change of inclination of the implant or
to a complete displacement. Since the bone in
the upper jaw is denser on the palatinal side,
the displacement is usually into the vestibular
direction and often we have to assume that
the vestibular cortical is fractured under the
periost. This fracture resembles a Greenstickfracture and it heals uneventfully.
Whereas we can and should compress the
spongeous bone to increase the stability in the
maxilla, we do not have this possibility in the
lower jaw. Therefore the osteotomy in the lower
jaw must be prepared almost to the size of the
core of the implant or slightly bigger, because
even the thick-necked KOS® implant (2.8mmd at
the neck) would fracture as soon as forces of
more than 80 Ncm are exerted.
In this context I would like to mention, that
the idea of the “pressure osteolysis” does not
refer to conical compression screw implants.
The so called “pressure osteolysis” created
“during implant insertion” has been described
in connection with cylindrical implants, however
scientific proof for its existence is missing,
and it is assumed to occur only at the apex of
implants. (As it is not possible to differentiate
between “pressure osteolysis” and the result of
a residual infection, many cases of “rest-ostitis”

may have been misdiagnosed).
In conical implants high insertion torques
concentrate on the flat or rounded apex area,
whereas pressure distributes evenly over the
whole vertical implant area in conical implants
and not in the apex of the implants. This
pressure distribution is effective. Furthermore
spongeous bone becomes condensed whenever
compression screw implants are inserted.
The process of condensing is described as
corticalization. During this corticalization the
flow through the osteons is cut off, osteons are
destroyed and compressed and they can no
longer be the source of osteonal remodelling
but only the target of osteons travelling from
unaffected bone areals. Since this takes more
time (depending on the distance from the point
of the initiation of a secondary osteon to the

implant surface), the time-span for carrying out
prosthetical work on KOS implants is increased.
Nevertheless is has to be mentioned here again,
that immediate splinting (and thereby loading)
is still the safest way of handling KOS and BCS
implants.
New designs of BCSÂŽ implants are available
with diameters of 5.5 mm, 7 mm, 9 mm, and
12 mm. The implants feature very sharp and
cutting threads. To place these implants after
a pre-drilling of 2 â&#x20AC;&#x201C; 2.5mmd often only requires
a considerable amount of axial pressure. This
pressure is exerted with the hand which is not
turning the ratchet. Note that theses implants
may alter their direction of insertion, if the
corticals which they touch are of an unequal
mineralization.

Fig. 11: Implants may touch or bypass one another inside the bone without creating any problem.
The requirement for inter-implant distance is smaller, if the implants provide a thin diameter and if
they are polished.

CMF.Impl.Dir. Vol. IV 2010

115

For KOS® implants the drill sequence has to be
regarded especially in the lower jaw. In the upper
jaw the bone may be so soft, that a wide implant
may be placed right after the initial pilot drill (the
yellow DOS1) was used to the full length.
For flapless insertions the oral mucosa is
completely disinfected with Betadine or a
similar agent. The insertion is planned according
to radiographs, mostly by panoramic overview
pictures. From this picture information about
the start of the insertion is taken, the length
of the implant is determined, and the question,
whether or not an opposite cortical should be
penetrated is answered.
Digital or bi-digital inspection will then help to
explore the site in the mouth. Special care must
be taken, not to slip off the ridge or to penetrate
the cortical in lingual or palatal direction.
Undercuts on the lingual aspect of the mandible
are explored also. Although cortical engagement
is for KOS® implants not as essential as it is for
BCS® implants (KOS® implants gain stability
by resting in compressed bone with strongly
reduced possibility to initiate remodelling), it
nevertheless is an advantage to position the
apex of the KOS® implant into cortical bone.

116

4.2 Insertion with open flap technique
If the surgeon is uncertain about the bone
morphology and fails to fixate the implant into
the bone, the preparation of a flap is indicated.
a.) Slim crestal flaps are an option in many
cases:
In a strictly crestal approach the top of
the crest is uncovered, but the flap remains
attached to the alveolar bone on both sides.
Under this relatively good vision often the secure
preparation and the insertion of a thin KOS®
implant (e.g. 3.0 or 3.2 mm) becomes possible
in thin ridges. The small flap is then sutured
around the implants.
b.) The full flap technique should uncover the
whole alveolar bone at least from one side. The
flap preparation is done para-crestally: usually
the cut is performed on the palatinal side, but
again strictly perpendicular to the bone surface.
These flaps offer the opportunity to punch th+e
flap and hang the flap over the implant heads
after a flap lengthening procedure (WassmundProcedure). Therefore the flap should not only
allow the insetion of the implant, it should also
allow closing over extractions and a sound
suturing. It is advisable to create rather large
flaps, because the patients will have less pain
if the flaps are large. The possibility of intraoperative changes of the treatment plan must
be taken into account: in some cases placing
a lateral implant instead of a BCS is necessary
and in those cases a larger flap is definitely an
advantage. When suturing after extractions,
note that the frontal area and areas over base-

plates should be closed first, because it is easier
to generate tissue in the distal maxilla (through
a flap lengthening procedure than in the front.
Closing tightly over base-plates is necessary in
order to preserve the blood clot for woven bone
formation.
c.) The exploration flap is used, if the crestal
width of the bone is sufficient for implant
insertion, but endangered structures or parts
of basal implants have to be passed by in secure
distance. A typical example for this exploration
flap is a small cut crestally to the mental nerve
followed by the careful preparation of the nervebundle. Under full vision of the nerve bundle the
implant may be inserted near the nerve, without
opening a full flap. The exploration flap is sutured
slightly and the sutures may be taken out on the
day after surgery.

4.3. Coping with non-parallel bone supply

• Finally, both KOS® and BCS® implants may be
equipped with “angulation-adapters” These
adapters are slipped over the abutments
and cemented with strong, permanent
cements (e.g. Fuji, Fusion, Panavia or
similar). Both the surface of the abutment
and the inner surface of the adapter must
be roughened with a coarse diamond
before the cementation takes place. After
the cementation the over-projecting top
of the abutment is ground down to the
adapter surface.

4.5. Lateral basal implants
After preparing a full thickness flap, the vertical
and the horizontal osteotomies are prepared.
After this the implant is inserted with gentle
tapping and the flap is closed. The impression is
taken typically right after the operation.

When using KOS® implants there are 4 good
options to overcome the problem of non- parallel
implants and divergent insertion directions:
• Using angulated KOS®A implants is a good
option in healed bone areas and if the
implant is being splinted to other implants.
KOS®A is contra-indicated for single tooth
replacement.
• KOS®B provides the possibility of bending.
The neck of the implant is 1.8mm in
diameter only, and bends of about 15
degrees are possible. KOS B implants must
be used in connection with other implants
in larger bridges. Usage as a single implant
is strictly contra-indicated.

CMF.Impl.Dir. Vol. IV 2010

117

Fig. 12a

Fig. 12b

118

Fig. 12c

Fig. 12d

CMF.Impl.Dir. Vol. IV 2010

119

Fig. 12e

Fig. 12f

120

Fig. 12f

Figs. 12a-g: After the tooth 13 had been
extracted, the socket is cleaned from soft
tissue remnants (Fig. 12.a). Then the overprojecting vestibular part of the bony extraction
socket is reduced (Figs. 12.b, c) and the vertical
slot is prepared (Fig.12.d). With the triple-cutter
the horizontal slots are prepared (Figs. 12. e,.f.).
The implant is tapped in completely (Figs. 12 g.).
Since after extractions often a V-shaped vertical
slot is left on the vestibular side of the alveolar
crest, the soft tissue might invaginate into the
slot and competitively prevent (woven) bone
formation. This can be avoided by moving down
larger parts of the flap towards the head of the
implant,- a procedure which can be compared
to a coronal repositioning flap in the periodontal
field. The sutures are always used as matrace
or double sutures (3.0 silk being the preferred

material) and those sutures should be left in 5 â&#x20AC;&#x201C;
7 days to allow the stabilization of the soft tissues
in the new position. If considerable amounts of
soft tissues are moved towards the head of the
implant, a nice aesthetic appearance is easier
to achieve.

CMF.Impl.Dir. Vol. IV 2010

121

Conclusion
Basal implants utilize cortical bone areas. They
are inserted in a bi-cortical (trans-osseous) way.
Because the stable and resorption-resistant
cortical bone is used, procedures are possible
in an immediate load protocol.
Compression screws are used as single tooth
implant and preferably in healed bone areas, i.e.
not in sockets. The rationale of compressing the
bone is the increase of mineralisation and the
prevention of remodelling originating nearby the
endosseous implant surface.
As basal implants are considered elastic
implants, they may be combined with natural
teeth. The treatment provider should keep
in mind however, that dental implants have
on average a higher life expectation than the
involved teeth. Hence constructions should be
planned in a way, that teeth which fail early can
be removed without endangering the overall
construction.

Guide for Authors
ID publishes articles, which contain information, that will improve
the quality of life, the treatment outcome, and the affordability of
treatments.
The following types of papers are published in the journal:
Full length articles (maximum length abstract 250 words, total
2000 words, references 25, no limit on tables and figures).
Short communications including all case reports (maximum
length abstract 150 words, total 600 words, references 10,
figures or tables 3) Technical notes (no abstract, no introduction
or discussion, 500 words, references 5, figures or tables 3).
Interesting cases/lessons learned (2 figures or tables, legend
100 words, maximum 2 references).

Literature Research and Review articles are
commissioned.
Critical appraisals on existing literature are welcome.

usually

Direct submissions to:
publishing@implantfoundation.org.
The text body (headline, abstract, keywords, article, conclusion),
tables and figures should be submitted as separate documents.
Each submission has to be accompanied by a cover letter. The
cover letter must mention the names, addresses, e-mails of all
authors and explain, why and how the content of the article will
contribute to the improvement of the quality of life of patients.